25 September 2010

24 September 2010

One of the things I love about this blog, is that a lot of my readers, like me, work odd hours. I enjoy seeing the timestamps on the emails and comments; a surprising number of them originate between 0100 and 0400 hours. I guess a lot of ER types get bored and read blogs on the night shift.

One of the things I don't like about my job is that I have to work nights. Don't get me wrong -- I worked nights exclusively for a few years before I had kids, by choice. I like the pace of night shifts, I like the occasional down time, I like the camaraderie that the night staffs always seem to enjoy, and I even learned to like the traditional post-night shift team meal of pancakes and beer. That was when I was working all nights. Now I just work the same fraction of nights as the other docs in our group, a handful per month, and I find them much harder. It's easier to flip the sleep/wake cycle when you're going to work five nights in a row. One or two stand-alone night shifts are a lot more disruptive to my biological rhythms. And it's well known that as you get older, your ability to handle the sleep deprivation gets less and less.

This is why I was interested to hear a lot of buzz recently about a medication called Provigil (Modafinil). It apparently is FDA approved for the treatment of "Shift Work Sleep Disorder," a disease which I am pretty sure did not exist before the good folks at Cephalon decided to market the drug to shift workers. It is basically a stimulant which is more effective than caffeine, milder than amphetamines, and with a lower side effect and dependence profile than other stimulants. I attended a few lectures at ACEP's Scientific Assembly which addressed this issue -- both from a quality of life perspective as well as a physician performance and patient safety perspective -- and I was surprised to hear an almost evangelistic level of enthusiasm for this drug from the speakers. I have personally known a few ER docs who have tried it and they also rave about its virtues. They say that you are just blissfully awake for that awful first night up, without the jitters from caffeine, without feeling edgy or off-kilter, and you are able to sleep the next day -- there's no hangover.

It's got me wondering. I have never self-medicated (other than with coffee or booze or the occasional antibiotic), and I am not about to start. If nothing else, it is a schedule IV med. (It's also on the FAA's list of forbidden drugs for a pilot to take, which is ironic since apparently the Air Force uses it to improve pilot alertness on long missions.) But I am tempted to take the commercial's advice and "ask my doctor about a free trial..."

I'd be interested to hear any experiences any of my readers might have with this medicine -- especially any of the under-reported down sides. It sounds too good to be true, which means it probably is.

EPILOGUE

I wrote this post in a slow moment of an overnight shift. I hadn't thought I was particularly tired, but once I was on my way home a wave of fatigue broke over me and really took me by surprise. I almost fell asleep at the wheel and drove off the road several times. Scary -- thank God for rumble strips on shoulders! Fatigue impairs your judgment; I should have gotten the hell off the road but I was afflicted with a severe case of get-there-itis. I managed to focus myself after the second or third time it happened and made it home without incident.

I don't think it makes a compelling point for or against Provigil, but it's a disturbing irony to occur three hours after writing a post on sleep issues...

20 September 2010

There was an interesting discussion on NPR's "Morning Edition" today about the dying art of the physical exam and how some teaching doctors are trying to re-emphasize it. (NPR is cool in that almost as soon as a story is on the air, there's a readable version at their web site.) Now I think that there's a certain amount of hyperbole over this issue, in that there's not really a serious trend to omit the exam in medicine. But it reminded me of an interesting exchange I recently had with Dr Bob at Medrants about the limited value of orthostatics. The point seems valid on the topic of the physical exam as well as postural vital signs: both are time-consuming evaluations which have a very low yield rate in terms of diagnostic and therapeutic information.

Again, don't get me wrong, I am not saying that I don't examine my patients -- I always do, and I have a fairly consistent approach to the complaint-focused exams I perform. But with a few very prominent exceptions, I often -- usually -- learn little from the exam. What I do learn is usually negative, meaning I note the absence of certain bad things. I see hundreds of abdominal pain patients, every one gets a careful abdominal exam, and in one or two I will find some "wow" finding that guides my treatment. I see thousands of patients with weakness, and a small fraction have a neurologic exam finding which leads me to a diagnosis. I'm not sure the "Chest Pain" exam has ever told me anything about the patient's condition.

So what I would say is that the exam is necessary, but it is often worthless, in that I learn nothing from it. It's worse than useless in many cases. Just because the patient does not have obvious peritonitis does not mean that he is not hiding appendicitis in there, and relying on a normal exam can actually have disastrous consequences.

It's funny, though, that the teaching authorities fall back on the "we love tests" trope as the reason many doctors de-emphasize the physical exam. Because I don't think that's right. We do a lot of tests, of course, but that's beside the point. Tests are ordered after the fact. We skim through the exam because it's just not that valuable a tool, and it's not even the most useful thing we can do at the bedside.

My preferred substitute for the physical exam, in terms of where I get the information that leads me to the necessary treatment, is talking to the patient. It's a crazy idea, I know -- a radical development in the field of medicine. But 90% of the pertinent information I get at the bedside is from what the patient tells me. It might be nice to perform a leisurely and thorough exam on every patient, but that takes a long time. In the real world where I have a finite amount of time to spend with each patient, I have to prioritize and allocate my resources, and talking to the patient is always my number one priority. This is followed by an exam, either thorough or desultory, depending on what the patient has told me and my level of concern.

Now I should point out that patients do expect to be examined, and it is important in building the rapport, especially in the ER. I have always felt the most powerful part of the exam for that purpose is the hand exam. I always start with it -- it's very intimate. You hold the hand, you look at the skin, the fingernails. You turn it over and caress it as you look at the palm, examine the fingertips and feel for the pulse at the wrist. The rest of the exam feels almost antiseptic in comparison -- you listen to the heart, putting a metal tool between the patient and yourself. But that initial touching at the hand is what seems to cement the relationship. So habituated am I to performing the ritual of the exam that every once in a while do I omit it (say a patient who wants a refill on some simple med) and I feel horribly guilty about it.

Is that physical contact what patients really value, though? Hard to say. I see all the patient complaints for our 100,000+ visit ER and "The doctor never examined me" is an infrequent complaint. Maybe that's just because we do a good job of examining everybody. A more common, almost universal complaint, however, is "The doctor didn't listen to me." At least as a driver of patient satisfaction, the verbal part of the interaction seems to be valued more than the physical (and patients are less tolerant of failure to listen).

And many physical exam maneuvers have become outdated. Pulsus paradoxus, for example. It should never be performed in any circumstance (at least in standard medical settings). Its value in the routine exam is nil -- literally nil -- because it's only going to be abnormal in patients with fairly severe disease. And in patients who are sick enough to have an abnormal pulsus paradoxus, there are many other ancillary tests with far more resolution capability: ECG, echo, CT, etc. Other elements of the exam are more what we call "mental masturbation." Fun to do, intellectually satisfying, but still ultimately valueless. Consider listening to the patient's chest and noting egophony or whispered pectoriloquy. I mean, that's cool, isn't it? I love the applied physics involved in how those findings appear. But what of it? Bear in mind that these are findings of severe, late-stage disease. They require wholesale changes in the lung tissue. They are highly specific for consolidation but not at all sensitive. If the patient is presenting with a respiratory complaint and is ill enough to have lung consolidation, the likelihood the patient will also be getting a chest x-ray is about 99%, and I'm getting much better information from the x-ray. In fact, my threshold for getting an x-ray should be well lower than my interest in egophony, since the x-ray is a better screening test.

In the premodern era, and in remote settings these things had great value. When you have no other ability to gather data, then you fall back on exam (so it is good to have the skills and the knowledge). In the current setting, whether in the office or the ER or wherever, it's important to recognize the severe limitations on the utility of the exam and relegate it to its proper role as a necessary but generally less important element of the overall evaluation.

17 September 2010

One of the nice things about medicine is that it is still a respected profession in the average community, and as I have become more involved in the medical staff of our local hospital, an inevitable corollary is that I have begun to get involved in local community activities: charitable foundations, local politics and the like. It's a time burden, but personally rewarding, so I don't mind, and if nothing else I get to meet lots of interesting people.

One day, not long ago, I walked into a board of directors meeting for one such activity. As I entered the crowded room, about ten minutes early for the meeting, a loud voice cut across the murmur of small talk and chitchat that precedes any such convocation:

"Hey, I know that guy! He took care of my heart!"

I really don't generally look forward to these interactions: meeting former patients in a social setting. There's usually (always) a complaint about how long they had to wait, or the smelly drunk in the gurney next to them, or the "real" diagnosis given to them by their follow-up doc. I looked over my shoulder, hoping somehow that I had been followed into the room by a cardiologist, but there was nobody. I turned back, resigned, to face my fate. A cheerful, ruddy-faced fellow was forcing his way through the crowd, followed by a small phalanx of hangers-on and goons. The entire assemblage had stopped chatting and was turning to see what the excitement was about.

Moments later, he was pumping my hand up and down and breathlessly gushing, "I don't know if you remember, but you saved my life about six weeks ago." He mimed a defibrillator going "zap." I had no recollection, of course, but I said "Yes, yes, I recall, but I am sorry because I can't remember your name...." If nothing else, that usually buys me some time to think. He introduced himself as [name of prominent regional politician redacted]. Still nothing, but I've a terrible memory for names and am good at faking it. "Oh yeah, I remember now. So how're you doing?"

"Oh great!" He began speaking to the crowd of people around us, "This guy fixed me up real good. I haven't had a problem since. You wouldn't believe the stuff they do there in the ER!" He began recounting the details of his visit to the assemblage, with a somewhat over-dramatized version of my own heroic role in the events. And I did begin to recall his case, with that prompting.

It was, from my point of view a totally satisfying case, though hardly heroic. A simple cardiac arrhythmia, symptomatic enough to require urgent treatment, and most effectively treated by DC Cardioversion (zap). His complaint and vital signs had gotten him a bed and me at the bedside promptly, despite presenting on a busy holiday. I remembered him as a pleasant professional middle-aged guy, frightened, with a very anxious wife at the bedside. We established a good trust, terminated the arrhythmia with some electricity, and he went home happy. I never made the association between his name and the powerful local politician with the same name. He had been in bed 3-2, which is in a double room, and was in the ED about three hours. Bizarrely enough, during that time frame, we had no fewer than three acute ST-Elevation MIs come in, and all three were briefly in room 3-1 before being whisked off to the cath lab.

So this fellow gets his own heart shocked and happens to get to overhear my "You're having a heart attack" speech to three temporary roommates. No wonder he thought we were so great.

I shook my head -- what dumb luck, that a guy in this position of influence should have had that one-in-a-million ER experience. And I had no clue who he was at the time! It makes me think of long ago, when I used to work in a large retail chain as a sales associate, we would get these "Secret Shoppers," or "spies" as we bitterly called them, who would come in posing as regular customers but actually rating the performance of the employees. He had been sort of a medical version of a secret shopper.

10 September 2010

10/10 muses on how Pride goeth before the fall, relating an embarrassing story about how the gods of medicine will bring you down for excessive cockiness. I too have paid that karmic debt, and since he started the confessional, I might as well carry on...

This was way back in residency. In fact, this occurred during the last few weeks before graduation. God damn, but I was at the top of my skills then. I could put in a central line* faster than taking a piss. I could intubate with my eyes closed. Chest tubes were such common events that I let medical students do them. I fancied myself the best at doing procedures in our entire residency program -- and not entirely without cause. I had gone the three years of doing central lines on a daily basis without ever causing a single pneumothorax**. People sought me out to do the difficult procedures. One attending wrote on my evaluation, "Dr Shadowfax is almost as good as he thinks he is."

So one day the ER was almost empty. I sat around shooting the shit with Rick***, a close friend and the chief resident in our program. He was working the acute room, and I was supposed to be supervising the interns, who were all surfing the internet. A sick old man came in by ambulance and Rick went to take care of him, so I tagged along. The patient was an emaciated fellow, semi-conscious**** and in respiratory distress. So we put him on oxygen, a breathing treatment, EKG, and Rick got the guy prepped for a central line. I leaned back against the counter, sipped my coffee and watched.

Now Rick was no slouch himself at procedures. I don't want to disparage him here. But I could not resist the temptation, nay, the sacred obligation, to issue a running commentary on Rick's technique as he attempted to put in the central line. Which is to say that I taunted him. Mercilessly. Creatively. Persistently. And the more I taunted him, the more apparent it became that Rick was just not going to be able to get that line in. Maybe it was my distracting him, or maybe it was just that the thin old man's chest heaving up and down made it really difficult to get the line in. Either way, after an extended and particularly eloquent riff on how he couldn't find his way to . . . well, I'll leave it at that rather than get too obscene . . . Rick slammed down his needle in the tray and said in irritation, "OK smart-ass, you give it a try!"

I made a big show of getting my tray ready while the radiology techs took a chest x-ray. I made sure to dispense plenty of advice to Rick about how best to line up the needles and scalpels and other elementary, condescending details. Rick just glared at me. I said, "Step aside, sonny, and I'll show you how it's done." I stepped up to the neck, found my landmarks, and in 30 seconds, the line was in. I pulled my gloves off with a flourish, and told Rick that if he had any further questions I would be happy to arrange a tutorial. Rick still just glared at me.

As I began to stride masterfully out of the room, we both noticed that the patient wasn't doing so well. His respirations were much more labored, his pulse was up, and his oxygen level was down. All of a sudden, the levity was gone and we were back to work, with a really sick patient. Of course all the docs out there know what happened, so I'll skip to the punchline: a repeat chest x-ray showed a pneumothorax. Rick suddenly had the biggest shit-eating grin on his face as he showed me the picture. "Well, doctor, you had better do something about that, hadn't you?" he said. So, faced with the deteriorating respiratory status of what was now *my* patient, I intubated him, sedated him, and put in a chest tube to relieve the pneumothorax.

That is the trifecta: central line followed by intubation and chest tube.

And all the while, I had to endure Rick's insightful commentary.

Karma.

*Central Line: a procedure where you shove a needle into the neck, usually into the jugular vein, and thread a catheter into or near the right atrium of the heart. Reserved for the sickest patients or those with no other veins to access.

** Pneumothorax: a rare but known complication of central line insertion in which the needle goes too far into the neck and punctures the apex of the lung. This causes the affected lung to collapse, worsens breathing (duh) and requires insertion of a chest tube -- a tube into the chest -- which re-expands the collapsed lung.

*** We're still friends, surprisingly.

**** Obligatory disclaimer: the patient was really out of it. Even I am not so unprofessional as to talk smack about another doc in front of a patient or family.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

Disclaimer

This blog is for general discussion, education, entertainment and amusement. Nothing written here constitutes medical advice nor are any hypothetical cases discussed intended to be construed as medical advice. Please do not contact me with specific medical questions or concerns. All clinical cases on this blog are presented for educational or general interest purposes and every attempt has been made to ensure that patient confidentiality and HIPAA are respected. All cases are fictionalized, either in part or in whole, depending on how much I needed to embellish to make it a good story to protect patient privacy.

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